Synchronizing Chest Compression and Ventilation in Cardiac Resuscitation

ABSTRACT

Apparatus for automatic delivery of chest compressions and ventilation to a patient, the apparatus including: a chest compressing device configured to deliver compression phases during which pressure is applied to compress the chest and decompression phases during which approximately zero pressure is applied to the chest a ventilator configured to deliver positive, negative, or approximately zero pressure to the airway; control circuitry and processor, wherein the circuitry and processor are configured to cause the chest compressing device to repeatedly deliver a set containing a plurality of systolic flow cycles, each systolic flow cycle comprising a systolic decompression phase and a systolic compression phase, and at least one diastolic flow cycle interspersed between sets of systolic flow cycles, each diastolic flow cycle comprising a diastolic decompression phase and a diastolic compression phase, wherein the diastolic decompression phase is substantially longer than the systolic decompression phase.

CROSS-REFERENCE TO RELATED APPLICATIONS

This application is a continuation application of and claims priority toU.S. application Ser. No. 11/357,931, filed on Feb. 16, 2006.

TECHNICAL FIELD

This invention relates to devices for cardiac resuscitation, and moreparticularly to devices for automatic control of chest compression andventilation.

BACKGROUND

Resuscitation treatments for patients suffering from cardiac arrestgenerally include clearing and opening the patient's airway, providingrescue breathing or ventilation with a manually operated bag-valve orpowered portable ventilator apparatus for the patient, and applyingchest compressions to provide blood flow to the victim's heart, brainand'other vital organs. The chest compressions may be delivered bymanually compressing the patient's chest in the region of the sternum orby the use of a powered chest compressor. If the patient has a shockableheart rhythm, resuscitation also may include defibrillation therapy. Theterm basic life support (BLS) involves all the following elements:initial assessment; airway maintenance; expired air ventilation (rescuebreathing); and chest compression. When all three [airway breathing, andcirculation, including chest compressions] are combined, the termcardiopulmonary resuscitation (CPR) is used.

There are many different kinds of abnormal heart rhythms, some of whichcan be treated by defibrillation therapy (“shockable rhythms”) and somewhich cannot (non-shockable rhythms”). For example, most ECG rhythmsthat produce significant cardiac output are considered non-shockable(examples include normal sinus rhythms, certain bradycardias, and sinustachycardias). There are also several abnormal ECG rhythms that do notresult in significant cardiac output but are still considerednon-shockable, since defibrillation treatment is usually ineffectiveunder these conditions. Examples of these non-shockable rhythms includeasystole, electromechanical disassociation and other pulselesselectrical activity. Although a patient cannot remain alive with thesenon-viable, non-shockable rhythms, applying shocks will not help convertthe rhythm. The primary examples of shockable rhythms, for which thecaregiver should perform defibrillation, include ventricularfibrillation, ventricular tachycardia, and ventricular flutter.

After using a defibrillator to apply one or more shocks to a patient whohas a shockable ECG rhythm, the patient may nevertheless remainunconscious, in a shockable or non-shockable, perfusing or non-perfusingrhythm. If a non-perfusing rhythm is present, the caregiver may thenresort to performing CPR for a period of time in order to providecontinuing blood flow and oxygen to the patient's heart, brain and othervital organs. If a shockable rhythm continues to exist or developsduring the delivery of CPR, further defibrillation attempts may beundertaken following this period of cardiopulmonary resuscitation. Aslong as the patient remains unconscious and without effectivecirculation, the caregiver can alternate between use of thedefibrillator (for analyzing the electrical rhythm and possibly applyinga shock) and performing cardiopulmonary resuscitation (CPR). In the mostrecent version of the guidelines promulgated by the American HeartAssociation (AHA) in 2005, CPR may now also be delivered prior todefibrillation shocks, even for patients presenting to the rescuer witha shockable rhythm such as ventricular fibrillation. In the most recentAHA guidelines, CPR generally involves a repeating pattern of 30 chestcompressions followed by a pause during which two rescue breaths aregiven.

Ventilation is a key component of cardiopulmonary resuscitation duringtreatment of cardiac arrest. Venous blood returns to the heart from themuscles and organs depleted of oxygen (O₂) and full of carbon dioxide(CO₂. Blood from various parts of the body is mixed in the heart (mixedvenous blood) and pumped to the lungs. In the lungs the blood vesselsbreak up into a net of small vessels surrounding tiny lung sacs(alveoli). The net sum of vessels surrounding the alveoli provides alarge surface area for the exchange of gases by diffusion along theirconcentration gradients. A concentration gradient exists between thepartial pressure of CO₂ (PCO₂) in the mixed venous blood (PvCO₂) and thealveolar PCO₂. The CO₂ diffuses into the alveoli from the mixed venousblood from the beginning of inspiration until an equilibrium is reachedbetween the PvCO₂ and the alveolar PCO₂ at some time during the breath.When the subject exhales, the first gas that is exhaled comes from thetrachea and major bronchi which do not allow gas exchange and thereforewill have a gas composition similar to the inhaled gas. The gas at theend of this exhalation is considered to have come from the alveoli andreflects the equilibrium CO₂ concentration between the capillaries andthe alveoli; the PCO₂ in this gas is called end-tidal PCO₂ (PetCO₂).

When the blood passes the alveoli and is pumped by the heart to thearteries it is known as the arterial PCO₂ (PaCO₂). The arterial bloodhas a PCO₂ equal to the PCO₂ at equilibrium between the capillaries andthe alveoli. With each breath some CO₂ is eliminated from the lung andfresh air containing little or no CO₂ (CO₂ concentration is assumed tobe 0) is inhaled and dilutes the residual alveolar PCO₂, establishing anew gradient for CO₂ to diffuse out of the mixed venous blood into thealveoli. The rate of breathing, or minute ventilation (V), usuallyexpressed in L/min, is exactly that required to eliminate the CO₂brought to the lungs and maintain an equilibrium PCO₂ (and PaCO₂) ofapproximately 40 mmHg (in normal humans). When one produces more CO₂(e.g., as a result of fever or exercise), more CO₂ is produced andcarried to the lungs. One then has to breathe harder (hyperventilate) towash out the extra CO₂ from the alveoli, and thus maintain the sameequilibrium PaCO₂. But if the CO₂ production stays normal, and onehyperventilates, then the PaCO₂ falls. Conversely, if CO₂ productionstays constant and ventilation falls, arterial PCO₂ rises. Some portionof the inspired air volume goes to the air passages (trachea and majorbronchi) and alveoli with little blood perfusing them, and thus doesn'tcontribute to removal of CO₂ during exhalation. This portion is termed“dead space” gas. That portion of V that goes to well-perfused alveoliand participates in gas exchange is called the alveolar ventilation (VA)and exhaled gas that had participated in gas exchange in the alveoli istermed “alveolar gas”.

Automatic ventilators capable of delivering desired airway pressures arealso known. U.S. Pat. No. 5,664,563, describes a ventilation systemcapable of delivering negative airway pressures. U.S. Pat. Nos.4,676,232, 5,020,516 and 5,377,671 describe a ventilator withventilation cycles synchronized with the cardiac cycle in order toenhance circulation. U.S. Pat. No. 4,326,507 describes a combined chestcompressor and ventilator that delivers a ventilation over a number ofcompression cycles and then delivers another series of compressioncycles during the period between ventilations.

While the current AHA recommendation is two ventilations every thirtycompressions, that recommendation was promulgated in large part becauseit was found that the delays due to switching back and forth betweencompressions and ventilation by rescuers was resulting in insufficientlevels of chest compressions and the resultant circulation. It isdesirable, in the case of mechanical devices to integrate the functionsof chest compressions and ventilations.

U.S. Pat. Nos. 6,179,793 and 6,752,771 describe an inflatable vest forassisting the heart in patients suffering from heart failure. Theinflation of the vest is synchronized with on-set of the systole phaseof the heart, when the left ventricular compresses to force blood out ofthe heart and through the aorta. The inflated vest compresses thepatient's chest and increases the intrathoracic pressure. This increasein pressure assists the heart in moving blood out of the heart andthrough the aorta. U.S. Pat. Nos. 4,198,963 and 6,171,267 describe adevice that synchronizes a chest compression cycle to the systolic phaseof cardiac activity. U.S. Pat. No. 6,213,960 describes a device forautomatic chest compression during resuscitation.

Synchronization of the ventilation cycle with the compression cycle isdescribed in U.S. Pat. No. 4,397,306. The patent proposes synchronizingan automatic chest compression device with an automatic ventilator, andrecommends that high pressure ventilation pulses be deliveredsimultaneously with the compression phase (i.e., when chest pressure isapplied), and that slightly negative ventilation pulses be deliveredsimultaneously with the decompression phase (i.e., when no chestpressure is applied). Compression and decompression phases are of equallength (50% duty cycle). The negative ventilation pulses are said “tomove greater amounts of blood into the chest during diastole”. Also, thepatent recommends introducing a conventional ventilation cycle everyapproximately sixth compression/decompression cycle, when no compressionis occurring. This is said to be valuable for sufficient alveolar gasexchange since very little air flow occurs during the positiveventilation pressure cycles that are synchronized to the compressionphase. While U.S. Pat. No. 4,397,306 reports that significantimprovements in pressure and flow were observed using the invention, thephysiological state of a typical patient differs fairly significantlyfrom the animal model used in those experiments.

In a typical cardiac arrest, the amount of time that a patient has beenwithout any blood flow is commonly greater than ten to twelve minutes,unlike animal models where no flow times are always less than 8 minutes,and in most experiments is less than 5 minutes. Under these prolongedconditions of ischemia, patients' vascular tone will be significantlycompromised as a result of insufficient metabolic energy substrates andnitric oxide release. This loss of tone manifests itself physically witha significant increase in the compliance of the vasculature, which, likeincreases in capacitance in an electronic circuit, cause an increase inthe intrinsic time constants of the system. This can be tested in modelssuch as is described in Crit. Care Med 2000 Vol. 28, No. 11 (Suppl.), orin animal models with extended durations of ischemia. As the authordescribes, the system of differential equations has been described in anumber of publications. In this specific instance, “the humancirculation is represented by seven compliant chambers, connected byresistances through which blood may flow. The compliances correspond tothe thoracic aorta, abdominal aorta, superior vena cava and right heart,abdominal and lower extremity veins, carotid arteries, and jugularveins. In addition, the chest compartment contains a pump representingthe pulmonary vascular and left heart compliances. This pump may beconfigured to function either as a heart-like cardiac pump, in whichapplied pressure squeezes blood from the heart itself through the aorticvalve, or as a global thoracic pressure pump, in which applied pressuresqueezes blood from the pulmonary vascular bed, through the left heart,and into the periphery. Values for physiologic variables describing atextbook normal “70-kg man” are used to specify compliances andresistances in the model. The distribution of vascular conductances(1/resistances) into cranial, thoracic, and caudal components reflectstextbook distributions of cardiac output to various body regions.” Inparticular, the time constants of venous return during the decompressionphase are significantly increased during prolonged periods of ischemia.

SUMMARY

In a first aspect, the invention features apparatus for automaticdelivery of chest compressions and ventilation to a patient, theapparatus comprising a chest compressing device configured to delivercompression phases during which pressure is applied to compress thechest and decompression phases during which approximately zero pressureis applied to the chest, a ventilator configured to deliver positive,negative, or approximately zero pressure to the airway, controlcircuitry and processor, wherein the circuitry and processor areconfigured to cause the chest compressing device to repeatedly deliver aset containing a plurality of systolic flow cycles, each systolic flowcycle comprising a systolic decompression phase and a systoliccompression phase, and at least one diastolic flow cycle interspersedbetween sets of systolic flow cycles, each diastolic flow cyclecomprising a diastolic decompression phase and a diastolic compressionphase, wherein the diastolic decompression phase is substantially longerthan the systolic decompression phase.

Preferred implementations of this aspect of the invention mayincorporate one or more of the following. The control circuitry andprocessor may be configured to cause the ventilator to deliver anegative ventilation pressure during the diastolic decompression phase.The time durations of the systolic compression phases and systolicdecompression phases may be approximately the same. The time duration ofthe diastolic decompression phase may be greater than twice the timeduration of the diastolic compression phase. The time duration of thediastolic decompression phase may be approximately four times the timeduration of the diastolic compression phase. The diastolic flow cyclemay comprise a second compression phase and a second decompressionphase, and wherein the negative ventilation pressure may be deliveredduring one of the first and second decompression phases and a positiveventilation pressure may be delivered during the other of the first andsecond decompression phases. The ventilator may deliver positive andnegative ventilation pressures during the systolic flow cycles. Negativeventilation pressure may be delivered during the majority of thedecompression phase of the systolic flow cycle. Positive ventilationpressure may be delivered during the majority of the compression phaseof the systolic flow cycle. The ventilation pressure may vary graduallyin an approximately ramp shaped variation from negative to positive andback to negative, with the pressure being approximately zero at theonset of the compression phase. The pressure may change rapidly frompositive to negative at or just prior to the onset of the decompressionphase. The ventilation pressure waveform may be at or near a peak at theonset of decompression. The compressions and ventilations may besynchronized with the patient's ECG to augment a patient's underlyingsystolic and diastolic activity. The apparatus may further comprise afluid infusion device. There may be both negative and positive pressuresavailable from the ventilator. Oxygen levels may be elevated to greaterthan 40%. The apparatus may be configured to be used for victims of bothcardiac and traumatic arrest wherein conditions of global ischemia maybe present and the reoxygenation process during resuscitation may putthe victims at risk of reperfusion injury.

In a second aspect, the invention features apparatus for automaticdelivery of chest compressions and ventilation to a patient, theapparatus comprising a chest compressing device configured to delivercompression phases during which pressure is applied to compress thechest and decompression phases during which approximately zero pressureis applied to the chest, a ventilator configured to deliver positive,negative, or approximately zero pressure to the airway, controlcircuitry and processor, wherein the circuitry and processor areconfigured to cause the chest compressing device to repeatedly deliversystolic flow cycles, each systolic flow cycle comprising a systolicdecompression phase and a systolic compression phase, and wherein thecontrol circuitry and processor are configured to cause the ventilatorto deliver a ventilation pressure during the compression phase thatincreases from approximately zero pressure at the onset of thecompression phase to approximately a maximum at or near the end of thecompression phase.

Preferred implementations of this aspect of the invention mayincorporate one or more of the following. The control circuitry andprocessor may be configured to cause the ventilator to deliver aventilation pressure that is negative at the onset of the decompressionphase. Fluids infused by the infuser may be configured to providemetabolic substances during reperfusion. The substances may be aminoacids. The amino acids may be aspartate or glutamate. The apparatus mayfurther comprise a defibrillator and infuser, and wherein thedefibrillator, compressor, ventilator, and infuser may be separatedevices and may be linked by a communications link. The apparatus mayalso further comprise an additional device to synchronize thedefibrillator, compressor, ventilator, and infuser.

In a third aspect, the invention features apparatus for automaticdelivery of chest compressions and ventilation to a patient, theapparatus comprising a chest compressing device configured to delivercompression phases during which pressure is applied to compress thechest and decompression phases during which approximately zero pressureis applied to the chest, a ventilator configured to deliver positive,negative, or approximately zero pressure to the airway, coolingapparatus for cooling gases delivered by the ventilator, wherein thecooling is configured to cool the lungs, heart and the pulmonary bloodflow.

Among the many advantages of the invention (some of which may beachieved only in some of its various aspects and implementations) arethe following. Improved blood flow is achieved by alternating a set ofsystolic flow cycles with at least one diastolic flow cycle. Thediastolic flow cycle has a lengthened decompression phase synchronizedwith a negative ventilation pressure The lengthened diastolic flow cycleprovides more time for venous filling, and thus better blood flow thancould be achieved with the approach taught in U.S. Pat. No. 4,397,306.

Other features and advantages of the invention will be found in thedetailed description, drawings, and claims.

DESCRIPTION OF DRAWINGS

FIG. 1 is a block diagram of one implementation of the invention.

FIG. 2 is a block diagram of the ventilator of one implementation of theinvention.

FIG. 3 is a timing diagram of the integrated compression and ventilationcycles of one implementation of the invention.

FIG. 4 is a timing diagram of the integrated compression and ventilationcycles of another implementation of the invention.

DETAILED DESCRIPTION

There are a great many possible implementations of the invention, toomany to describe herein. Some possible implementations that arepresently preferred are described below. It cannot be emphasized toostrongly, however, that these are descriptions of implementations of theinvention, and not descriptions of the invention, which is not limitedto the detailed implementations described in this section but isdescribed in broader terms in the claims.

FIG. 1 shows a block diagram of one implementation. Microprocessor 14controls in an integrated fashion the ventilator functions 15, chestcompressor 12, drug infuser 14, and defibrillator/pacer 13.Physiological sensors 2, sternal motion measurement methods such asaccelerometer-based sternal displacement measurement 3, and signalprocessing 9 to filter and process these various signals such asend-tidal carbon dioxide measurement (EtCO₂) and pulse oximetry (SpO₂)are used to determine the patient's 11 physiological and physical state.A separate laptop 17 may communicate with the microprocessor 14, andmay, in fact, be used to control the therapy delivered by the ventilator15, chest compressor 12, drug infusor 14, and defibrillator 13.

Referring to FIG. 2, which shows a block diagram of the ventilatorportion of one implementation, microprocessor 14 controls the deliveryof various therapeutic gases, compressed CO₂ 26, O₂ 25, and room air 24.Pressures for these gases are controlled by regulators 34 and mixed withvalves 35 to achieved the desired partial pressures for each of thegases. A cooler/heater/humidifier 33 is provided to condition the air.In one implementation, a heat exchanger is provided that cools the gasmixture to 1-2 degrees centigrade as a means of inducing mildhypothermia. The heat exchanger may be an electrically-powered elementincorporating a Peltier-effect element or may incorporate a cold storageelement such as a liquid nitrogen or dry ice storage element. In thecase of the cold storage element, the rate of cooling is controlled byinsulating the cold storage element, providing for a heat conductingwindow in the insulation, and adjusting the surface area of the heatconducting window.

FIG. 3 shows a timing diagram of one implementation. Three waveforms areshown. First is the patient's ECG (the ECG shown is representative of anECG following return of spontaneous circulation (ROSC); a very differentECG would typically be present prior to ROSC). The second waveform isthe chest compression force applied by the automatic chest compressiondevice (in the figure, compression pressure rises as the waveform movesdownwardly). The third waveform is the ventilation pressure applied tothe airway (in the figure, pressure is positive above the axis, andnegative below the axis).

In some implementations, the compression-to-ventilation ratios can bevaried from the current AHA recommendation of two ventilations every 30seconds. For example, one ventilation may be delivered for every fivechest compressions (a ratio closer to that of a normal adult).

In the implementation shown in FIG. 3, there are five chest compressioncycles 48 during period 50. Each compression cycle has a 50% duty cycleof compression to decompression ratio and an 800 msec cycle length (400msec compression phase; 400 msec decompression phase). Each cycleincludes an onset of compression or downstroke (44) and an onset ofdecompression or upstroke (46). These compression cycles are configuredto improve systolic flow, and so can be called “systolic flow cycles”.

Following the five systolic flow cycles, there is a “diastolic flowcycle” 52. The diastolic flow cycle begins with a shortened compressionphase 54 of 200 msec duration, followed by a lengthened decompressionphase 56 of 600 msec duration, then a second shortened compression phase58 (200 msec), and a second lengthened decompression phase 60 (600msec). During the diastolic flow cycle, the automatic ventilatorproduces a negative pressure phase 62 (600 msec) to induce a negativeintrathoracic pressure (approx. −2 kPa) aligned with decompression phase56. This results in increased venous return to the right atrium(diastolic flow), thus increasing blood flow during the subsequentcompression phase 58. The ventilation pressure ramps up (64) toapproximately +2 kPa during the compression phase 58 and remainsconstant at +2 kPa during the subsequent 600 msec decompression phase66. In the implementation of FIG. 3, ventilation assistance is notprovided during the systolic flow cycles (ventilation pressure is zeroduring those cycles).

FIG. 4 shows another implementation, in which systolic flow may befurther enhanced by short ventilation cycles 68 synchronized with thesystolic flow cycles 50. The ventilation cycles are synchronized withthe compression and decompression phases of the systolic flow cycles,taking the shape of a ramp with approximately zero pressure at the onset70 of the compression phase, and rising to a maximum positive pressureduring the compression phase. In the decompression phase of the cycle, asimilar triangular ventilation pressure waveform is used, with themaximum negative pressure 72 occurring just slightly prior to(approximately 40 msec prior) to the onset of the decompression phase,so that the airway pressure is definitively negative at the onset ofdecompression, so as to maximize diastolic reflow. This linear ramp witha zero-crossing at the onset of compression has the advantage ofproviding an airway that is close to a homogeneously neutral pressure atthe onset of compression, so that at the compression downstroke 44 andthe resultant rise in intrathoracic pressure, the airway collapses for aportion of the compression phase. By collapsing the airway, the volumeof the lungs themselves are maintained during the chest compressioncycle, acting effectively as bellows on each side of the heart tosqueeze the heart during a compression thus enhancing systolic flow. Insome implementations, chest compression is provided by aload-distributing band such as that manufactured by ZOLL CirculatorySystems of Sunnyvale Calif. The diastolic flow cycles 52 occur after anumber, preferably five or six, of systolic flow cycles 50. Thediastolic flow cycle may have approximately a 20-30% compression dutycycle, with a decompression phase 62 that is approximately 640 msec induration. Subsequent to ROSC, a victim's own heart is pumping andcirculating blood, but usually with reduced efficiency. In someimplementations, ventilations after ROSC are delivered withoutcompressions. But in other implementations, compressions after ROSC mayalso be delivered in a similar pattern to that used during cardiacarrest. The compressions after ROSC differ in two important respects:(1) they are synchronized to the QRS of the patient's ECG, as shown inFIG. 3; and (2) they are of reduced compressive force. A compression ofreduced force and synchronized to the ECG QRS will augment the naturalflow of the patient's hemodynamics enhancing recovery.

Many other implementations other than those described above are withinthe invention, which is defined by the following claims. For example,different shapes and different numbers of compression and ventilationwaveforms than those shown in FIGS. 3 and 4 may be used.

1. Apparatus for automatic delivery of chest compressions andventilation to a patient, the apparatus comprising: a chest compressingdevice configured to deliver compression phases during which pressure isapplied to compress the chest and decompression phases during whichapproximately zero pressure is applied to the chest; a ventilatorconfigured to deliver positive, negative, or approximately zero pressureto the airway; control circuitry and processor, wherein the circuitryand processor are configured to cause the chest compressing device torepeatedly deliver systolic flow cycles, each systolic flow cyclecomprising a systolic decompression phase and a systolic compressionphase, and wherein the control circuitry and processor are configured tocause the ventilator to deliver a ventilation pressure during thecompression phase that increases from approximately zero pressure at theonset of the compression phase to approximately a maximum at or near theend of the compression phase.
 2. The apparatus of claim 1 wherein thecontrol circuitry and processor are configured to cause the ventilatorto deliver a ventilation pressure that is negative at the onset of thedecompression phase.